Vagotomy (Truncal & Highly Selective)
What the Examiner Expects
Division of vagal nerve fibers to reduce gastric acid secretion, historically performed for peptic ulcer disease refractory to medical management. Truncal vagotomy divides both vagal trunks at the esophageal hiatus, denervating the entire stomach plus the hepatic and celiac branches — this eliminates gastric motility in the antrum, so a drainage procedure (Heineke-Mikulicz pyloroplasty or gastrojejunostomy) is mandatory. Highly selective vagotomy (parietal cell vagotomy) divides only the branches to the acid-secreting fundus and body while preserving the nerve of Latarjet to the antrum, maintaining gastric emptying and eliminating the need for drainage.
Key Examiner Focus Points
- Truncal vagotomy requires a drainage procedure (pyloroplasty or gastrojejunostomy)
- Highly selective (parietal cell) vagotomy preserves antral innervation — no drainage needed
- Truncal vagotomy divides both anterior and posterior vagal trunks at the GEJ
- Postvagotomy diarrhea occurs in ~10% of truncal vagotomy patients
- Rarely performed today given effective PPI therapy; know for boards
Common Curveballs
Patient presents with a perforated duodenal ulcer and you perform a Graham patch — should you add a vagotomy?
Controversial. In the acute setting with peritonitis, most surgeons perform a Graham patch alone and start PPI therapy + H. pylori eradication postop. Definitive acid-reducing surgery is reserved for recurrent ulcers after medical management failure.
After truncal vagotomy and pyloroplasty, the patient has persistent watery diarrhea
Postvagotomy diarrhea — occurs in up to 10% of patients. Manage with cholestyramine (binds bile salts), dietary fiber, and antidiarrheal agents. Rarely requires surgical revision (reversed jejunal interposition segment).
Recurrent ulcer after highly selective vagotomy
Incomplete vagotomy or missed H. pylori infection. Test and treat for H. pylori, maximize PPI therapy. If truly refractory, consider truncal vagotomy with antrectomy (most definitive acid-reducing operation, lowest recurrence rate of ~1%).